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The gap between rich and poor is bad for our health

The gap between rich and poor in Canada is growing. Organizations across the country, from the Conference Board of Canada to the Canadian Centre for Policy Alternatives have recognized the rise of income inequality in Canada. For some, this concentration of wealth is an unremarkable trend, but for many more it is worrying change in the Canadian character. What is indisputable to those of us working in the health care sector is its effect on health of Canadians. Health is a concern common to all, regardless of political affiliation, and does not exist in isolation from this growing problem. Evidence continues to mount that rising income inequality is contributing to the deterioration of the health of all people in Canada, regardless of their income level.

There are over 170 studies on income inequality and its relation to health. Data has demonstrated that in more unequal countries people live shorter lives, a higher proportion of children die in infancy, obesity is more common, as is mental illness and the use of illicit substances. It should come as no surprise then, that people in countries with high income inequality rate their health as worse than those in more equal nations.

Canada is no exception. In 2012, the Canadian Medical Association released a study showing how self-reported health varies with income level. Then CMA President Dr. John Haggie said, “When it comes to the well-being of Canadians, the old saying that wealth equals health continues to ring true. What is particularly worrisome for Canada’s doctors is that in a nation as prosperous as Canada, the gap between the ‘haves’ and ‘have-nots’ appears to be widening.” In 2012, higher income respondents were 29% more likely to describe their health as “excellent” or “very good” than lower income respondents. In 2009, that difference was only 17%. At that time, lower and higher-income Canadians were also equally accessing health care services. However, in 2012, Canadians who earned less than $30,000 a year accessed health care services 16% more than those earning $60,000 or more.

Not only are we falling behind when compared to our past selves, but also when compared to other high-income countries. For example, in the case of income inequality and child wellbeing, we are stuck in the mediocre middle behind countries like Denmark, Spain, Finland and Belgium. The same pattern is repeated for mental health, obesity, drug abuse and a multitude of other health ills.

Here at home, Canadians mirror such cross-partisan support. A recent Broadbent Institute study found that 58% of Conservative supporters, 71% of New Democrats and 72% of Liberals are all willing to pay more to protect social programs and make reducing income inequality a higher priority.

As a family doctor who sees the impacts of these public policies on the front lines, I find myself nodding in agreement to these sentiments and calls to action. While there are some clinical interventions I can use to address income and health, systemic policy change will be the ultimate lever of change. It is time for both federal and provincial governments to raise additional revenue from those most able to afford it in order to support social programs that help redistribute income and provide immediate health benefits for all people in Canada. In the face of mounting evidence of this growing problem and its consequences for our health and the health of our patients, our governments can no longer sit on their hands. The time for leadership on this issue has come.

Danyaal Raza is an Ottawa-based family physician. Follow Dan on Twitter, @DanyaalRaza.

Thanks fo rthe great column. %featured%The more we can expose the links between income inequality and health, the more people will wake up to the fact that this growing gap hurts us all.%featured% You’ll also find excellent work over at http://alltogethernow.nupge.ca This campaign has been talking about income inequality for more than three years now.

Deb, thanks for kind words and website. Dr. Fullerton, the CMA survey did not address the specific health services used, so I’m afraid I can’t answer your question with respect to their survey. However, this may shed some light – “Lesson from Canada’s Universal Care: socially disadvantaged patients use more health services, still have poorer health.” http://www.ncbi.nlm.nih.gov/pubmed/21289349

However, as I say in my piece, we also have to lend our voices to broader advocacy around the issue. The Canadian Medical Association has shown remarkable leadership this year with a policy agenda around social determinants of health. We should push other physician organizations to follow their lead and when possible, work with community and patient groups doing the same. Yes, this is outside our typical work environment, but there are opportunities out there to engage the issue this way.

%featured%There is no argument that there exists an association between income and health. However, the relative income hypothesis (i.e., what you present as the association between income *inequality* and health) is still up for debate.%featured%

Wilkinson et al. (2006) (or, the meta-analysis of “over 170 studies” in your article) is only one side of this debate. Lynch et al. (2004) conducted a similar meta-analysis of 98 studies and came to the contrary conclusion that “there seems to be little support for the idea that income inequality is a major, generalizable determinant of population health differences within or between rich countries.”

I understand the policy implications would be significant should the hypothesis be true. However, the current state of evidence on the issue is mixed at best, and it is best if the hypothesis is presented that way as to avoid obfuscation and misleading conclusions.

Below are examples of academic research that renders the issue mixed:

Gravelle, H. (1998). “How much of the relation between population mortality and unequal distribution of income is a statistical artefact?” British Journal of Medicine. Vol. 316(7128): 382 – 385.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.